• Monica W Harbell, Natalie R Langley, David P Seamans, Veerandra Koyyalamudi, Molly B Kraus, Frederick J Carey, and Ryan Craner.
• Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ, USA Harbell.Monica@mayo.edu.
• Reg Anesth Pain Med. 2023 Oct 1; 48 (10): 495500495-500.

Background And ObjectivesStudies show variable spread with thoracic erector spinae plane (ESP) injections. Injection sites vary from lateral end of the transverse process (TP) to 3 cm from the spinous process, with many not describing the precise site of injection. This human cadaveric study examined dye spread of ultrasound-guided thoracic ESP block at two needle locations.MethodsUltrasound-guided ESP blocks were performed on unembalmed cadavers. Methylene blue (20 mL, 0.1%) was injected in the ESP at the medial TP at level T5 (medial transverse process injection (MED), n=7) and the lateral end of the TP between T4 and T5 (injection between transverse processes (BTWN), n=7). The back muscles were dissected, and the cephalocaudal and medial-lateral dye spread documented.ResultsDye spread cephalocaudally from C4-T12 in the MED group and C5-T11 in the BTWN group, and laterally to the iliocostalis muscle in five MED injections and all BTWN injections. One MED injection reached serratus anterior. Dorsal rami were dyed in five MED and all BTWN injections. Dye spread to the dorsal root ganglion and dorsal root in most injections, though more extensively in the BTWN group. The ventral root was dyed in 4 MED and 6 BTWN injections. Epidural spread in BTWN injections ranged from 3 to 12 levels (median: 5 levels), with contralateral spread in two cases and intrathecal spread in five injections. Epidural spread in MED injections was less extensive (median (range): 1 (0-3) levels); two MED injections did not enter the epidural space.ConclusionAn ESP injection administered between TPs exhibits more extensive spread than a medial TP injection in a human cadaveric model.© American Society of Regional Anesthesia & Pain Medicine 2023. No commercial re-use. See rights and permissions. Published by BMJ.

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